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,QCITY OF STOCKTON • <br /> P484A 1 S DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name AgcAws- ys , 1 " C Date n f L APPROVED: BY THE P1;;rZRKS DIRECTOR <br /> (Owner/Contractor <br /> Address20B 0 �,�hLQ11 S'1' 7*FIaxPhone 51Q —fo52" t/S4 C, Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> ry <br /> City rn 9, t'j JI St � <br /> ate _Zip q62 Water Pollution Prevention Plan or the most current version <br /> of <br /> Location of Proposed Work,etc. Si Aq-walk (2kS cAn 2.1k-1- ane+ M the City of Stockton Storm Water Pollution Prevention <br /> P I Mainte ce Staff Guide,whichever is applicable. <br /> 351 Cyuinc�j anti ZIO(v Lr�y�ewood <br /> Owner/Contractor Address By) at. <br /> Estimated Starting Date_NCt 1 ar la Completion Date /Joy /4 Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Dr',II tLAA XYVA6 1 fiW0 ((Eorlh ¢11n a, 7166? In, iL- -aA on LhAk TAA iphe WkLI <br /> CA 351 6h1ki.ell 11 ah Is aa"od o Q-4[Oki o�\ II ' vhu1 1 r t 1l--CAh ce,{ ey. St <br /> It d,.,k IC- <br /> ATTENTION: <br /> cATTENTION:Applicant/Contractor-you are responsible to `� D� <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ J <br /> gutter from score mark to score mark adjacent to the parcel; 2 �J Z 7 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ / / L/ <br /> The above named applicant hereby requests permission to <br /> \d Sewer Tap Deposit.................. $ 0 <br /> f,xt TOTAL DEPOSIT ...... $ Z- <br /> <9 <br /> rnkQs . �2Vocablr <br /> Building Permit No. 11 -07w <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> CONTROL NUMBER. <br /> CALL (209) 937-8W TO REQUEST A CONTRA <br /> fiUMBEIR NO LESS THAN 24 HClURS, RUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF 1`-K. <br /> CONTROLS <br /> Show sketch above or refer to drawing submitted ei' <br /> Y.i!'{5Y�".m <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinances,resolutions l <br /> Standards and Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs, or damages resulting from injury to persons,death of person or damage to property <br /> occurring at the site of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> al 19'25-N37-9r? <br /> y� <br /> Signed (/ 1 Phone: <br /> 1-'-Permittee(white) 2nd-Insoection (oink) ftrd-Fila lvannw\ dlh _Finnnro r,e,haat <br />